Basic Information
| Provider Information | |||||||||
| NPI: | 1447221304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNINGER | ||||||||
| FirstName: | CAMILLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1934 VIA CTR | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920816056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604486691 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5717 PACIFIC CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921214250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588591188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | A115660 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.